Tyndale Residence Medical Form

Student Life

"As an RA this year I hope to create a strong brotherhood between the guys in my dorm, increase their passion for God and have a blast doing it!"

Andrew Ball

Tyndale Residence Medical Form

All information in this form is confidential.

***Note: You DO NOT need your doctor to fill out this form. If you have any questions please contact Jeff Abraham, Residence Director.

Surname: *

First: *

Middle:

Birthdate: *

DD/MM/YYYY

Health Card: *

Province: *

Have you ever had the following:

Tuberculosis: *

If yes, specify dates:

HIV: *

If yes, specify dates:

Rheumatic Fever: *

If yes, specify dates:

Hepatitis: *

If yes, specify dates:

Malaria: *

If yes, specify dates:

Do you have any drug allergies?: *

If yes, please specify:

Do you have any food allergies?: *

If yes, please specify:

Are you currently on any medication?: *

If yes, please specify:

Have you received, or are you presently receiving psychiatric or professional counselling?: *

If yes, please provide a summary:

Please give the date (month & year) of most recent immunizations

Please provide dates for ALL listed.

Tetanus: *

Diptheria: *

Polio: *

In order to complete the medical form you must have a recent tuberculosis(TB) skin test performed. Please record the results and date of the test below.

TB skin test result:

Date TB skin test completed:

Please list any hospitalization or surgeries you have had: *

If you have not had any surgeries or hospitalizations, type NONE.

Please list any significant diseases or disabilities you have had or currently have: *

If you do not have any significant diseases or disabilities, please type NONE.

Call: 1-877-TYNDALE | (416) 218-6757
Email: admissions@tyndale.ca
25 Ballyconnor Court Toronto,
Ontario M2M 4B3 [ Map ]